It’s time to move away from the deficit model that is implicit in much discussion about the social determinants of health, and instead take a strengths-based cultural determinants approach to improving the health of Aboriginal and Torres Strait Islander people.” – Professor Ngiare Brown
The following opinion is published from Crikey and not NACCHO policy : We welcome your comments below
Closing the Gap goals not met” the headline read, on the stories spruiking the new report on indigenous health and conditions on Monday. That’s presumably ctrl-shift-F7 on some subeditor’s keyboard.
The outcomes are always disappointing in Closing the Gap, and disappointment at the outcomes of Closing the Gap has now become an annual Australian ceremony, in which everyone nods in sorrow, rather than in anger, and vows to do more.
The report was started as a way of bringing attention to the gap between life conditions of indigenous and non-indigenous Australians. It has now become the opposite: a sop to our consciences, a way for people to believe that “something is being done”. The report itself is a brochure, light on chunky statistics and heavy on photos of grinning children, case studies and video links. If you’re about to open a juice bar/Reiki massage parlour and you need a brochure, whoever put together “Closing the Gap 2017” will do you proud.
“Closing the Gap” as an approach to assessing progress in indigenous life-conditions has long since outlived its usefulness. It needs to be abolished and broken up into several reports. It has many problems, but the major one is that it overaggregates. Firstly, it aggregates Aboriginal people and Torres Strait Islanders (or, more exactly, the latter more or less disappear entirely), two quite different peoples, with different histories — and from that, different strategies towards creating fully modern-traditional societies.
Secondly, it aggregates the conditions of urban/suburban/regional-urban Aboriginal people on the one hand, with remote-area Aboriginal people. There’s a degree of disaggregation in the meat of it, but for the most part they are lumped together. In everything from health to employment, that obscures rather than illuminates. The employment, health, etc, problems of Aboriginal people in Mt Druitt may be far more to do with the problems of such for outer-suburban working-class/benefit-class people in general — with some fun added extras — rather than those of a community who live 1000kms from the nearest convenience store.
But the aggregation of “challenges” and “problems” is itself a problem. The report covers everything from health to employment to youth suicide and back to literacy, all in one big go. Yes, yes, they’re all related. But they’re also all not, and emphasising the autonomy of separate sectors may be a part of tackling them more effectively — and getting the public to think about them as being more readily addressable. The report puts them all on the same plane, and they clearly aren’t — morally, politically, causally.
Take health and employment, for example. We are all embodied subjects, with the same bodily form and structure, and good health is a precondition to a fully meaningful life and full social and political participation. “Employment” is a thing that is one way of doing that. Yes, everyone who wants it, should have access to it, and currently, it is a requirement to exercise social power and clout. But “maximising the avoidance of coronary heart disease”, and “maximising full employment” are quite different types of goals, which simply look the same, if put in the same language.
Thus the report notes (with some embarrassment) that while there has been some gains (not much) in employment for urban and regional Aboriginal people, for remote-area people, employment levels remain at 35%, as opposed to a national level of 72%. Really?
There’s high unemployment in former mission/camp societies, based on nomadic kinship societies, in an era of FIFO, automation, in the middle of the desert? No shit. What if we abandoned the idea that such communities need to have a full wage-employment model, or anything like it, and find other pathways (and measures) to autonomy, self-development and self-reliance by those communities?
Hence, the key difference: because there is no good level of poor health outcomes. The report is maddeningly aggregated here too, using measures that do not yield much insight into the specificity of problems, but one fact stands out clearly. No matter how much they try and disguise it with and/but language, and the ctrl-shift phrases “disappointing”, “more needs to be done”, the fact remains that in key outcomes — community mortality rate, infant mortality, and life expectancy — there has been no progress in 20 years. None. All these measures have improved for Aboriginal people, but only at the rate they’ve improved for non-indigenous people. The gap hasn’t narrowed an inch. That is failure on a grand, indeed total, scale.
The health statistics deployed in Closing the Gap are bloody useless, and a deeper dive will be required — I half suspect that the choice of stats is now being used to make the report a way of obscuring how dire things are — but you can read through the gumment-report smoking-screen ceremony. Health outcomes are terrible because chronic diseases — type 2 diabetes, coronary heart disease, lung conditions — are so high. But so too are diseases unknown, or very rare in non-indigenous communities, such as TB and worm infections. And here we come to another problem of, you guessed it, aggregation.
For decades now, the mantra has been the inter-relation of all conditions of health — physical, social, mental, cultural. This was a justifiable reaction to the sort of 20th-century approach, which was to tackle health problems by more or less spraying communities with DDT from aeroplanes. But one suspects it has now become a block to thinking and to the taking of decisive action on distinct conditions.
With that comes a second problem: the detailed mainstream reporting on Aboriginal health, and policy, is terrible, just terrible. For some years we were beset with Aboriginal health “squalor porn”, feature stories of the horror of petrol-sniffing, etc, with photos for the Saturday morning newspaper readership. That has now disappeared, only to be replaced by near-total indifference, and lack of information.
One looks in vain for any story, from people who have some expertise, as to how these parts fit together. Is alcoholism the main or overwhelming factor in high chronic disease rates, or is chronic disease more evenly spread across the population? Are the distinct indigenous-only* conditions such as TB and worm infections (some of which lead to blindness) exacerbated by such chronic conditions, or do they occur relatively autonomously? What role does lack of everyday access — pharmacies, 24/7 doctors — play in the worsening of chronic conditions? What role does poor literacy and low education rates play in problems of self-care and regime maintenance (taking pills, diet, limb care, etc). Even the sole focus on life expectancy as a single number is misleading. Ten years less, on average, than a non-indigenous person is bad enough, but there is a question of quality of life. Unmanaged diabetes/heart disease/lung disease may mean death at 65 — but it means exhaustion and illness at 40, dialysis at 45, oxygen at 50, amputations and blindness after that.
None of this is put before the public or discussed. Nor is there any discussion of how a “disaggregated” approach to Aboriginal health — i.e. nationwide-focused priorities — might yield better results. That’s what we used to do, in the West, and places like China still do. Is there any discussion of that? Quite possibly there is, but I don’t want to have to read 300 academic articles to find it. The discussion and debate, rather than the hand-wringing, should be out in the public. In this, Aboriginal health academics must shoulder a great deal of the blame. There are many good people in this field, but very few who appear to have any interest in communicating the debates to a wider public. They appear to be caught up in the state-policy-academia triad, essentially using their academic work as a form of lobbying of state instruments — rather than trying to raise wider public support for varying strategies.
For example if one disease — type 2 diabetes, as example, and also likely culprit — was identified as a, or the, major central factor in chronic disease, would not a focused campaign against it, with diversion of resources to it, be preferable to ineffectiveness spread evenly across the board?
In the 20th century, southern Europe and Turkey tackled malaria by “draining the swamps” where mosquitoes bred, part of great patriotic and public campaigns to wipe out the disease. It’s a measure of how distant that is that when the “drain the swamps” metaphor re-appeared in Donald Trump’s campaign in 2016, no one knew where it came from. We could do the same in Aboriginal health by involving the public. “Closing the Gap” needs to go. Or save money by simply making 2018’s report a photocopy of 2017, because it will be pretty much the same.
We need three separate reports: one on health, housing and food/nutrition, one on social and educational conditions, and one on work and employment. Yes, yes, they’re related. But forms of work and education are complex questions of competing models, based on different social ideals. There is no competing model between being well and being ill. We need more specific, concrete goals over shorter time-spans — three, five, seven years. The 2031 goal is bullshit in most cases. We have made no progress in 20 years on these key conditions, so there is no reason to believe we will make any in the next 15, using the current approaches.
We need more active choices, as to where the money and effort go, rather than the arse-covering process of doing a useless bit of everything. And we need academics to take the time to write a few articles that they won’t be able to count towards their career publications points, to let us know the debates within the field, and the proposals for more effective strategies. And please, less photos of brown people grinning. There are times when the report looks like a Trans Australia Airlines Corroboree tourism brochure from 1951. Time to turn the page on “Closing the Gap”, and look, especially in health, to more targeted, concrete, imaginative and audacious strategies, and raise our ambitions to immediate and palpable gain.